The purpose of this assignment is to look at psychosocial factors which have influenced an individual’s perception and behaviour towards their health and illness. The focus will be on a patient who is a non compliant type II diabetic who is reluctant to change his ways and improve his health and diabetes. To comply with the NMC The Code (2008) on confidentiality I have called my patient George. Health locus of control, learned helplessness with issues relating to depression has been incorporated to help explore the theories behind why George may act in this way.
Psychosocial looks at both the psychological and social aspects of a person’s life. The psychological aspect for an individual looks at their mental and emotional health and the social looks at their social life, their role in society and support they receive from others. Rana and Upton, (2009) state that psychosocial “involves aspects of both social and psychological behaviour”.
Perception can be defined by Rookes et al (2000) as a process which involves the recognition and interpretation of stimuli which register on our senses. Perception can be perceived as how we make sense of the environment around us using our sense organs which are touch, sight, taste smell and taste. This does not however, consider a person’s interpretation of events.
George is a 75 year old gentleman who is a type II insulin dependent diabetic. He had been admitted to the ward due to unstable blood glucose levels due to being noncompliant with his medications and diet. He has daily visits from the district nurse to check and re-dress his leg ulcers and to monitor his blood glucose levels. The district nurse believes that George is not taking his insulin as recommended which is causing side effects of his diabetes to exacerbate.
George is a solemn looking man; he is unkempt and takes no pride in his appearance. He comes across as quite depressive in nature and in general in low spirits. Whilst on the ward, it was quite difficult to make conversation with George. He did not converse with other patients and only communicated with the health professionals when needed. George has been on his own for some time and may find socializing with others quite difficult. His low mood may hinder him from opening up and developing new relationships.
George is a retired builder who lives alone in a small bungalow; his only income is a state pension and has no real social input. He has little contact with his family members or neighbours, which has left him socially isolated. George’s only social support at present is the daily visit from the district nurse. George may depend on this service, the reliability of knowing he will have a visitor every day, checking on him. George may feel if he becomes compliant with his diabetes he may lose this social support and be completely on his own. Age UK (2009) quotes that loneliness and isolation are not the same thing: the causes of loneliness are not just physical isolation and lack of companionship, but also sometimes the lack of a useful role in society. Social Justice’s (CSJ) Older Age review interim report (2010) stated in their report that research and evidence shows that as you become older, are suffering from an illness and have an inadequate level of income can put you more at risk of becoming socially isolated.
The World Health Organization (2003), outline evidence on how important social support and good social relations made contributions to health, It went on to say that people that lack emotional support, especially those who suffer from a chronic illness, have increased chance of experiencing less well-being, depression and more complications from their chronic illness, it can also lead to poor mental health. Because George is suffering from diabetes, a chronic illness he is more likely to have decreased optimism, low self-esteem, a poor quality of relationships and that it increased his vulnerability to loneliness. Murphy (2006)
George has a poor diet consisting of convenience foods such as microwave meals and finger foods such as cakes, sausage rolls and pasties, which he gets from his local shop. Acheson (1998) stated in the Independent Inquiry into Inequalities in Health Report, that “people on low incomes have insufficient money to buy items and services necessary for good health” and that “people in lower socioeconomic groups tend to eat less fruit and vegetables.” As George’s only income was his state pension, he would only venture out to his local shop which was at the end of his street, George only shopped there for convenience and due to his poor mobility because of his ulcerated legs; he did not have to travel far. He did not drive as had lost his license due to his ill health. Small shops tend to stock limited groceries and feel this could have limited his access to fresh fruits and vegetables. (Southall ; Roberts, 2002) state that depressive mood has been related to eating and dietary problems, as well as to low self-esteem, stress, low levels of social support, and avoidant coping skills. Low self-esteem and increased stress are independently associated with depressive mood.
Rotters (1954) Health Locus of Control, the theory is based on internal and external locus of control (LoC). External factors are seen to believe that events are unrelated to their actions and thereby determined by factors beyond their control, for example fate and circumstance and internal factors are seen to believe that events are a consequence of their own actions. People with internal LoC tend to be more prone to making changes and taking control of their lives. Conner et al (1995). They believe that their health-related outcomes are for the most part determined by their own choices and behaviours and are more likely to make positive changes to their health.
George appeared to have an external locus of control, as people with an external locus of control can lead to feelings of helplessness, hopelessness and depression. Maier et al (1976). He allows health professionals to take control of his health and to look after his diabetes and has little sense of responsibility to work in partnership and relate advice to personal lifestyle. Although George has received help from the diabetic nurse and dieticians, George still does not make any changes to improve his health or to change his diet. George is aware he needs to take his insulin for his diabetes, but is not compliant at all times with all meals which indicates that this partly shows by having an internal LoC as he will often help himself. Ogden, (2007) researched whether a person could have both external and internal LoC. As George was self administering his medications, he showed signs of having an internal LoC by taking some responsibilities with his medication.
An external locus of control can contribute to how a person copes with depression. Maier et al (1976). They will rely on doctors to overcome their depression instead of trying to help themselves. Relying on this type of help only decreases George’s self esteem as it does not help him to make lifestyle changes and improve self worth. In turn this contributes to having feelings of helplessness and hopelessness which contribute considerably to depression. This can then lead to a theory called “Learned Helplessness”.
Martin Seligman (1975) developed a model of depression based on the theory of learned helplessness. He researched that lack of personal control over a long period of time can affect a person’s health, negative situations and having no control can lead to learned helplessness.
Learned helplessness can have principle characteristics of depression and is a learned behaviour. When a person is placed in a situation where a particular outcome is or appears to be independent of his responses, he learns that his responses are ineffective. The affected individual may conclude that any responses he makes will be powerless to affect the outcome. The helpless subject may progress through successive stages of fear and anxiety to a deep depression. Learned helplessness also affects other psychological processes: motivation is reduced with no incentive to try new coping responses. Cognition and inability to learn new responses to overcome prior learning that trauma is uncontrollable and emotion, the helpless state which resembles depression. Seligman (1975). Other characteristics similar to depression are lack of positivity; creativity and healthy self image. Lack of motivation will cause feelings of hopelessness believing that they are incapable of doing better and feeling inadequate can all lead to depression and are all related to learned helplessness.
George may be a person who has always been in control of his life and since becoming diabetic and suffering with leg ulcers George maybe more angry and frustrated as he needs more help from health professionals as his health is beyond his control. George may have tried controlling his diabetes but if was not having the effect he required may have become depressed which then led to learned helplessness, if George could not help himself then allowed the district nurses to deal with it. “Learned helplessness is the giving-up reaction, the quitting response that follows from the belief that whatever you do doesn’t matter.” Seligman (1975)
With the district nurses visiting George and helping him with his diabetes and insulin, George’s personal control has been taken away from him and instead allows the district nurses to take responsibility of his diabetes. A patient’s development of dependence following exposure to disempowering care can contribute towards learned helplessness. Seligman (1975). The district nurses dis-empower George taking away his responsibility for his diabetes, implying he is unable to do it himself, by unintentionally helping George this may have made him feel inadequate to look after himself. George may have adopted the thought that the district nurses are dealing with his diabetes and have taken that control away from him. This is evident in hospital as well as George will comply whilst in hospital as nurses will help with medications at all meal times but when he goes back home, he appears to revert to his old ways by not eating healthily and not taking his insulin allowing the district nurses to take control of his diabetes.
George’s low self esteem and possible depression hinders him from making any positive changes in his life. George appears to fall in the category of stable/unstable attribution. This is where an individual may experience a negative event such as a chronic illness are more likely to feel helpless and depressed and unlikely to help themselves due to low self-esteem. Abramson et al (1978) suggests that the degree of helplessness and subsequent depression varies with the type of attributions individuals make about the cause of the uncontrollable events. If the cause of the situation is perceived as due to permanent, recurring factors, depression is a more likely response than if the situation is due to temporary factors. George’s leg ulcers are taking some time to heal which in turn has been affecting his mobility; this could be contributing to George’s low mood. With his diabetes not being controlled, the symptoms he is experiencing could be another factor bringing George’s mood down, the constant feeling of being unwell.
George may also be lonely and if complies with his diabetes then he may not get any visits from the district nurses and will not see anyone. Rosenberg (1965) defined self-esteem as the degree to which persons accept and value themselves and, as such, give them a basic feeling of self-worth. Chamberlain ; Haaga (2001) put forward that the presence of self-esteem reflects a dysfunctional self-rating process as it evaluates one’s global worth as a person and predisposes people to feeling depressed or anxious (as a potential failure or criticism or mistake may affect one’s future self-esteem). George displays low self esteem and shows this by not taking control of diabetes, and although has had many appointments with the diabetic nurse to try and improve his symptoms, to improve his health he still is non compliant and does not appear to care. This could be because of his low self esteem, having little self worth and may feel like a failure as he has little control over his health and any control he did have may be overridden by health professionals.
Rational non-adherence could be another reason for George’s noncompliance with his diabetes. The theory looks at why patients do not comply with their health needs as they do not believe it is in their best interest. They believe that the treatment will not make them better or will cause them more problems. Banyard (2002). George has a chronic disease and although can be improved, will always be a diabetic. Knowing this information George may feel there is no need to change his habits as the condition will never be cured. He also suffers with leg ulcers and knows that his diabetes could be the cause of them. He may feel he will always have health problems for as long as he has diabetes regardless of whether he is compliant with his medications.
George is quite a solemn man in looks and in mannerism. He makes no effort with his appearance and the same with his diabetes. He appears to have lost control of his health or given up on improving his health and allows health professionals to deal with them. Having been offered the services of the Diabetes Nurse and Dietician George does not make any changes with his diet and feel his lack of motivation and low self esteem prevents him from making any positive changes in his life.
George displays signs of depression and with health professionals helping him with his diabetes adopts the learned helplessness theory and allows them to take over knowing they will do it for him. His external locus of control confirmed that George lacked the motivation to take control and responsibility of his own health and allowed the health professionals to take responsibility for his diabetes even though the responsibility was still his. The links between learned helplessness and depression showed very similar traits and helped explain why George did not make the right choices for himself and how they hindered him and impacted negatively on his health.
George was the compliant patient in hospital but only because everything was done for him. He did not have to do his medications as the nurse would administer them and his food was catered for, having diabetic friendly foods. Once back home George would have to fend for himself and this is where he became non compliant.
His rational non adherence could explain why George never made any changes to his lifestyle. He believed that as he would always be a diabetic, although could improve the disease could not cure it so was there any point in trying to improve the situation and especially as diabetes came with other health complications which would be beyond his control.